Unlisted code denied for authorization
First time interacting with the health insurance system.
My ENT submitted 3 codes (I think) for preauthorization for septoplasty w/ turbinate reduction I'm having in Feb.
ENT notified me that one of the codes (an unlisted code) was denied and I will have to pay partly out of pocket ($X,000).
Questions
Is it hopeless to get insurance to pay for this? Should I act before the surgery or just communicate with insurance after? What process should I follow to try to get this covered?
My ENT and I strongly believe this particular technique is medically necessary to correct my breathing.
Info from ENT
An authorization could not be processed because it is an unlisted code. Dr. has been using this code for many years and has never been able to get insurance to approve it, yet we still try. He has also done many appeals on this code with no success, thus he does not do them anymore.
It is an unlisted code, so we cannot bill, but you can try to bill your insurance for it after the procedure if you would like, but you would still need to pay out of pocket prior to the surgery.
I also recently received a copy of a letter my insurance sent the provider after my consultation asking for medical necessity info for two codes. This presumably third code is not listed on this letter.
Timeline
11/6 – had consultation w/ ENT on functional improvements; scheduled surgery for Feb 12/29 – ENT office submitted preauthorization to insurance 12/29 – insurance replied with request for more info to determine medical necessity 1/5 – I called provider and learned of the out of pocket cost; "1 code was denied" 1/13 – I emailed provider to ask for additional info about the out of pocket cost 1/20 – I received copy of medical necessity request letter for 2 codes (letter dated 12/29)
No other communication to/from insurance or provider.
Codes
From medical necessity letter:
30465 Bilateral Procedure – Widening of nasal passage 21235 Bilateral Procedure – Obtaining ear cartilage for grafting The provider said the declined unlisted code was for extracorporeal septoplasty but I have no identifier beyond that.
Thank you!
submitted by /u/zerfgog
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